Listening Not Labelling: Honouring Different Perspectives In Medical Care
In this blog post we’ll discuss how to respond when patients see things differently
“The patient lacks insight...”
It’s not uncommon to hear this phrase in clinical practice. I have to admit to always feeling uncomfortable when it is said.
Firstly, I would really dislike being described as lacking insight particularly if I disagreed with medical recommendations.
Secondly, I think “lack of insight” risks becoming similar to “mechanical fall” in terms of usefulness for patient care, and as a geriatrician this rings alarm bells.
For context, geriatricians generally discourage the use of the phrase “mechanical fall” as it limits exploration of all the possible contributing factors to a fall for this person - a cornerstone of managing the risk of future falls. You could think of it as a type of premature diagnostic closure.
Similarly if we notice a mismatch between medical recommendations and patient choices, then label this as a “lack of insight”, we miss a vital opportunity to explore
What’s important to them
What drives their decisions
What information sources they trust (or distrust) and why
Put simply, we stop trying to understand their drivers early. And without this understanding we can’t really help them achieve their health goals.
Helping our patients means doing the work to understand what direction they want for their health and why
I have a theory that terms such as this are used for patients who don’t fit typical patterns for our healthcare knowledge and rather than doing the extra work we use a label to lay the problem solely at their feet.
But, I also can hear the frustration when this label is used by clinicians, this tells me that clinicians do want ways to help patients get better outcomes for their health.
Harnessing Health Literacy
The concept of health literacy is often raised concurrently with the concept of lack of insight. As clinicians we should ask ourselves “Have I done everything I can do to make this information accessible to this person?” And this includes identifying and acknowledging concerns they have that might. We won’t know how much of an impact these concerns have unless we ask.
How can I help my patients?
Consider reasons why someone may have a different approach to their health than your recommendations.
Could it be due to any of the following reasons: gaps in knowledge or information, low mood, apathy, fear, a change in cognition, other communication needs due to disability or neurodivergence, do they have different priorities to the medical team, have the had previous (negative) experiences, are they receiving conflicting advice from family members? You can probably add your own reasons from your experience
Ask yourself
“What judgements am I making about this person or their choices?”
“Have I done all I can to help them access the information they need to make decisions?” This includes listening to their understanding
And start with an open question to find out more, avoiding judgement or implied judgement
Acknowledge the difference of opinion
When I have been the 3rd, 4th or 5th person in a line discussing and issue I find it useful to acknowledge this upfront, including the frustration of being repeatedly questioned
“I know you have discussed this with a lot of doctors”
“I’m here to learn more about what’s important to you, and see if I can help with the options”
Listening with curiosity
Listen to what they are saying to discover the true meaning, without judgement
Listen to and question your own narratives or resistance about their choices. Could there be biases at play?
If they say certain options are out of the question or are absolutely necessary this indicates some strong feelings. Find out more - ask permission to explore further. This might sound like
“It sounds like this has come up before / you’ve thought about this a lot? Could you share what happened / what your thoughts are?
“Thanks for sharing that with me, can I ask what is about x that you are concerned about?”
Respond to cues and respond to emotions
This goes hand-in-hand with listening - use any clues to find out what the person is thinking and to help you understand what is most important to them.
It can be as simple as a sigh which might indicate the conversation is going over old ground.
You can test your understanding by naming what you notice, people will often share more when they feel acknowledged
“It sounds like you’ve been over this many times…”
“It seems like that idea brings up some sadness for you, could you tell me more about how you’re feeling?”
Ask them for their approaches/solutions and discuss these
One useful communication microskill is Ask-Tell-Ask. Asking helps you understand their perspective, telling adds your knowledge of possible options, which they then have the opportunity to include in their ideas for moving forward
“What do you think would help?”
Avoid jargon
This can turn up in common words or phrases e.g. mobilises, activities of daily living, transfers, deterioration, guarded prognosis, primary, negative, unremarkable. Can you think of better ways to explain these words or phrases? We use them so often we may not realise they lack meaning outside of clinical world
If it is important to use a medical term always explain it
“this is called …. (have you heard of it?). This means...”
(Interestingly even the word jargon is jargon, we might replace this with using plain English)
Check your understanding using microsummaries
“Let me check I have got this right, your biggest worries are …?”
Check for their understanding
e.g. using the teach-back method or a modification of this.
Let’s lose labels and create real change
When you find that your patient’s approach to their health differs from medical recommendations, that is the start of your journey of understanding.
And it can be incredibly satisfying to explore their core concerns, provide reassurance, explore plans that help achieve their goals, and support them change their health for the better.
For more on health literacy
World Health Organisation Definition https://www.who.int/news-room/fact-sheets/detail/health-literacy
Nutbeam, D., & Lloyd, J. E. (2021). Understanding and Responding to Health Literacy as a Social Determinant of Health. Annual review of public health, 42, 159–173. https://doi.org/10.1146/annurev-publhealth-090419-102529
A deeper exploration of Health literacy
Useful tools
Teachback resources https://teachback.org/
BRAN: Patient leaflet on discussing interventions using the acronym BRAN (Benefits, Risks Alternatives, Do Nothing) from Centre for Perioperative Care NHS UK
AFP article on Motivational interviewing
